Systemic Spatial Inequalities in China’s Elderly Care: Multi-Scale Diagnostic Evidence for Sustainable Healthy Landscapes in a Monocentric Metropolitan Region

Population aging is reshaping regional health systems, but the decisive variable is not only aggregate capacity—it is where care is placed. Optimization studies often reduce spatial imbalance to technical inefficiency, leaving the structural and institutional production of inequality unexamined, with less-developed regions remaining largely marginalized in spatial scholarship. Applying a structural–locational nexus to China’s Wuhan “1+8” City Circle—a monocentric metropolitan region with a steep urban–rural gradient—this study integrates multi-scale exploratory spatial analysis to diagnose system-wide and subunit-level structures and identify typology-specific density hotspots, thereby quantifying variation across service, organizational, and functional classifications. The multi-scale diagnosis reveals a “monocentric collapse” (system-wide CV = 102.67%), where extreme internal fragmentation in core urban districts (CV = 223.66%) coexists with structural marginality in sparsely covered rural counties (CV = 95.33%). Crucially, this spatial polarization is likely structured by institutional divergence: social organizations exhibit extreme core concentration driven by market-oriented spatial selectivity (CV = 238.03%) despite non-profit mandates, whereas facilities operated by government organizations approximate a random-like, geographically dispersed administrative scaffolding (CV = 57.95%), serving as the only reliable spatial anchor for peripheral regions. Functional differentiation further demonstrates that high-intensity facilities remain heavily clustered in the primary center, whereas elderly apartments selectively anchor across sub-centers. These findings reframe spatial inequality not as an incidental planning failure, but as a systemic structural outcome of territorial governance that constrains sustainable eldercare development. Achieving sustainable healthy landscapes under rapid population aging requires spatially targeted interventions—steering market forces toward underserved peripheries; implementing functionally differentiated planning standards; reinforcing a three-tier public network to remedy rural structural deficits; and establishing cross-jurisdictional coordination.